Consent Forms – SAMPLE only, for your review.
If you are new to my practice, before our first formal appointment you may complete consent and informational forms through the client portal, on-line. I would be sending you a Link to the email you provide when we establish our working relationship.
Important information from the consent form is shown here. You will complete all forms on-line and we can discuss in person when we meet.
Welcome
By making this decision to seek psychotherapy, you are also making a commitment of time, money, and energy. Always remember that the time we spend together is your time. I make every effort to meet you where you are on your own journey but if you should have preferences or questions about anything, please bring it to my attention. We can discuss to your satisfaction and if needed I can help set up a meeting with another mental health professional for a second opinion.
Psychotherapy Sessions and Fees
I offer a service that has value and your payment is a recognition of that fact, as well as providing me income that I depend upon to continue in my practice and my pro-bono activities in the community. Know that I appreciate the sacrifices you make to pay for your time with me. It will help us focus on you and your problem quickly if you plan to pay at the beginning of each session. I accept debit, health savings card or credit card and use Quick Books to process those payments. Cash and check payments in person are preferred and I have started charging a fee for card usage.
If we agree that we can work together on your problem, our first session together will usually be two hours long, and will cost $280. After our first long session, typical sessions will be 45 to 60 minutes. My typical 45 minute session fee is $125. A full hour is $140. If you become involved in legal proceedings that require my participation, you will be expected to pay for my time, even if the request comes from another party.
Unless we both agree cancellation was unavoidable and we cannot find another slot in the same week, once an appointment session is scheduled, you will be charged a $60 fee, unless you provide 24 hour advance notice.
Insurance
Insurance companies require providers to furnish a diagnosis and may ask for records, which I must provide. Your issues that bring you to therapy may not meet criteria required for diagnosis. In that case, we would not be able to bill insurance. Medicare is the only insurance provider I will bill. I am out of network for all other providers and if I can determine that you have a mental health diagnosis, I can provide you what is called a Superbill, which lists diagnosis, sessions and fees that you paid to me. You can then submit for reimbursement to your company and once you meet your deductible, they would cover some part of the claim. Additionally, you understand that, by using your insurance, you authorize me to release information to your insurance company.
Cash payments for my services
If you pay directly for my services (everyone not seeing me under Medicare as the Primary) I can provide you a statement via email for your records, at your request and usually automatically. You may use the statement titled ‘for insurance reimbursement’ that contains an F code diagnosis, to seek reimbursement from your insurance company.
Psychotherapy
In the past twenty years, psychotherapy methods have blossomed beyond traditional talk methods to include many methods that I use, such as family and couple specific methods, mind-body connection, and anything from trauma work to personal growth with EMDR.
I aim to use short-term methods and usually dispense with an exhaustive history and get straight to the root problem. Therefore, it is important for you to take care to complete the patient history and problem forms completely and carefully. This will save us both time and you money.
I also offer intensive, longer sessions that have an educational component, especially for intimate couples. We can talk more about the most suitable methods for your situation, though you can be assured that the sessions of psychotherapy will require that you take a very active part and I will always aim to end each session with a calming, and encouraging send-off.
For the therapy to be most successful, you will need to work hard and practice both during our sessions and at home. Though therapy has many benefits, there are risks. Often things seem worse just before they get better. For example, because therapy often involves dealing with trauma and strong feelings, you may remember repressed and disturbing memories and feel very strong negative emotions.
Though there can be no guarantee, I will do my very best with my innate intuition and empathy as well as all of my skills to help you, and be assured that research shows that therapy is likely to lead to better relationships, better day to day function, solutions to specific problems, and reductions in feelings of distress.
Contacting me
The phone number is my personal cell phone that we may use for text and phone calls once we have established a mutual agreement on our means of communication. I will make every effort to return your call within a few hours. If you are unable to reach me and feel that you cannot wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call.
Website and Email and Text Communications
I have a professional website for my business as a psychologist. You may access and review the information that I have on my website and, if you have related questions or suggestions, we can discuss this during your therapy sessions. I use email communication and text messaging only with your permission and in ways that we will discuss in a therapy session. Generally, your email and text messages with me should be limited to things like setting and changing appointments, billing matters and other related issues. If you need to discuss a clinical matter with me, please feel free to call me so we can discuss it on the phone or wait so we can discuss it during your therapy session. The telephone or face-to-face context is the most secure method of communication. Once you have used my online client portal, you may use that message service as well.
Social Media and Web Searches
I have a web presence that is unrelated to my professional duties as a psychologist and I do not communicate with patients through social media platforms. If I discover that I have accidentally established an online relationship with you, I will cancel that relationship.
Nowadays there is an incredible amount of information available about individuals on the internet, much of which may be known to that person and some of which may be inaccurate or unknown. If you encounter any information about me through web searches, or in any other fashion for that matter, please discuss this with me during our time together so that we can deal with it and its potential impact on your treatment. For instance, often clients review providers on various websites. Mental health professionals cannot respond to such comments or errors because of confidentiality restrictions. If you encounter a disturbing review, please feel to discuss it with me in a session.
Confidentiality
If you need specific clarification or advice I am unable to provide, formal legal advice may be needed, as the laws governing confidentiality are quite complex. In general, the privacy of all communications between a patient and a psychologist is protected by law, and I can only release information about our work to others with your written permission. But there are a few exceptions.
In most legal proceedings, you have the right to prevent me from providing any information about your treatment. In some legal proceedings, a judge may order my testimony if he/she determines that the issues demand it, and I must comply with that court order.
There are some situations in which I am legally obligated to take action to protect others from harm, even if I have to reveal some information about a patient’s treatment. For example, if I believe that a child, elderly person or disabled person is being abused or has been abused, I may be required to make a report to the appropriate state agency.
If I believe that a patient is threatening serious bodily harm to another, I am required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient. If the patient threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection. If a similar situation occurs in the course of our work together, I will attempt to discuss it with you before taking any action.
